Clean Intermittent Catheterization Before Initial Urodynamics Reduces Urinary Tract Infection and Improves Bladder Storage Function in Acute/Subacute Spinal Cord Injury: A Prospective cohort study

Technical Summary: Clean Intermittent Catheterization Before Initial Urodynamics in Acute/Subacute Spinal Cord Injury

Problem Statement
Neurogenic lower urinary tract dysfunction (NLUTD) is a prevalent complication of spinal cord injury (SCI) that significantly increases the risk of urinary tract infections (UTIs) and potential upper urinary tract damage. While guidelines recommend performing an initial urodynamic study (UDS) within three months of injury to guide management, real-world constraints—such as resource limitations and equipment availability—often delay this procedure. This delay creates a clinical dilemma regarding the optimal bladder management strategy while awaiting UDS: should clinicians maintain an indwelling urethral catheter (IUC) to ensure continuous drainage, or should they transition to clean intermittent catheterization (CIC) earlier?

Current literature suggests that prolonged IUC promotes bacterial biofilm formation, while CIC mimics physiological filling and voiding cycles. However, it remains unclear whether the choice of pre-UDS management affects the risk of symptomatic UTI immediately following the invasive UDS procedure, which itself is a known risk factor for infection (reported incidence 16–30%). Furthermore, the impact of these management strategies on bladder storage function (compliance, capacity, stability) at the time of the initial UDS is not fully characterized in the acute/subacute phase.

Methodology
This prospective observational cohort study was conducted at a tertiary rehabilitation center in Wuhan, China, between January 2025 and April 2026. The study enrolled 271 inpatients with SCI (within 6 months of injury) and NLUTD requiring catheterization. Participants were stratified into two groups based on their bladder management strategy prior to their first UDS:

• IUC Group (n=107): Patients who maintained a continuous indwelling urethral catheter from injury until the UDS.
• CIC Group (n=164): Patients who had established a planned CIC regimen for at least 3 days prior to the UDS.

Key Procedures and Measures:

• UDS: Performed using a standardized air-charged cystometry system following International Continence Society guidelines. Medication regimens (anticholinergics, beta-agonists) were not altered prior to testing.
• Primary Outcome: The incidence of symptomatic UTI within 72 hours post-UDS, defined by physician diagnosis, antibiotic initiation, and supporting clinical/laboratory evidence (fever, new/worsened incontinence, positive leukocyte esterase/nitrite, or urine culture ≥10⁵ CFU/mL).
• Secondary Outcomes: Urodynamic storage parameters, including neurogenic detrusor overactivity, bladder compliance, and maximum cystometric capacity.
• Statistical Analysis: Logistic regression was employed to identify risk factors for UTI, adjusting for baseline variables such as sex, time from injury, and medication use.

Key Results

• UTI Incidence: The CIC group demonstrated a significantly lower incidence of post-UDS symptomatic UTI compared to the IUC group (2.4% vs. 16.8%). Multivariate logistic regression confirmed that being in the IUC group was an independent risk factor for UTI (Adjusted OR = 5.149; 95% CI: 1.426–18.594; P = 0.012).
• Bladder Function: The CIC group exhibited superior bladder storage profiles at the time of UDS. Specifically, they showed significantly lower rates of low bladder compliance (<30 ml/cmH₂O) and higher maximum cystometric capacity compared to the IUC group. The IUC group had a higher prevalence of neurogenic detrusor overactivity.
• Baseline Differences: The IUC group had a significantly shorter time from SCI to UDS (median 47.5 days) compared to the CIC group (median 103.5 days), likely reflecting the time required to train patients/caregivers for CIC. The IUC group also had a higher proportion of male patients and lower usage of anticholinergic or β3-agonist therapy.

Significance and Claims
The study concludes that in patients with acute or subacute SCI, adopting a "CIC-first" pathway prior to the initial UDS is associated with a reduced risk of procedural UTI and improved bladder storage function compared to maintaining continuous IUC.

The authors propose that the protective mechanism of CIC is twofold:

1. Microbiological: Reducing the bacterial burden and biofilm formation associated with indwelling catheters.
2. Functional: Conditioning the bladder to physiological filling-voiding cycles, thereby maintaining better compliance and mucosal blood perfusion. This functional preparation may render the bladder more resilient to the stress of rapid filling during UDS, reducing susceptibility to micro-injury and subsequent infection.

The paper suggests a redefinition of the UDS role in clinical practice: rather than serving strictly as the "starting point" for treatment, UDS should be viewed as a "checkpoint" to calibrate and optimize a management plan that has already been initiated. Consequently, the authors advocate for the early implementation of CIC (potentially combined with empirical pharmacotherapy for detrusor overactivity) even when access to UDS is delayed, particularly in resource-limited settings. This approach may help patients navigate the early "infection-prone" phase of SCI-induced immunosuppression syndrome (SCI-IDS) more safely.

Limitations
The authors acknowledge the study's non-randomized nature, which introduces potential selection bias, though baseline clinical profiles were largely comparable. Additionally, the lack of pre-UDS urine cultures for asymptomatic patients limited microbiological analysis, and the single-center design necessitates caution regarding generalizability to primary care settings. Future randomized controlled trials are recommended to validate these findings.